Medical History Guidelines

Present Medical History: Present problem list should be noted here, either kept separately or within each PCP progress note. The problem list must be inclusive of all problems whether a separate list or within each PCP progress note.

Previous Medical History: A proper and accurate medical details in full should be maintained about the individual concerned. Medical document should be updated every 3 years in case of adults and 5 years in relation to paediatric patients.

Medical history of family: A family medical history is a record of health information about a particular person and his or her immediate blood relatives. This allows finding information about common disorders, such as heart disease, high blood pressure, stroke, certain cancers, and diabetes. It should be updated every 3 years for adults and every 5 years for paediatric patients.

Allergy Status: Medication allergies should be noted here. If the member has no known allergies or history of adverse reactions , this should be prominently noted. Allergies to environmental allergens, food, pets, etc, should also be noted. Allergy histories should be obtained by the first visit and updated at least every three years for adults and every five years for pediatric patients.

Social history: This is another segment of the medical history where info about family, occupation and recreational aspects of the patient's personal life that have impact on his health like food habits, smoking, drinking alcohol, drugs addiction, exercise etc should be significant updated every 3 years in case of adults and 5 years in case of paediatric patients.

Alcohol usage history: It is another major factor that has impact on health condition of any individual. History of alcohol usage should be reported in documentation and should be updated in medical records every 3 years.

Illicit drug usage: A properly devised record should exist for any drug usage by the individual concerned as it is another major contributing factor on disability and impairment. The history should be updated at least every 3 years.

Smoking: smoking is another factor contributing for large scale side effects on human body especially respiratory system, blood circulatory system, immunity, damage sexual organs and cause several cancers. So it is advised to have updated history every 3 years.

Smoking history for Adolescents: People in the age group of 13-17 years who are habitual smokers should have a updated documentation obtained by 3rd visit or within a year of 1st visit whichever is the earlier.

Discourage smoking in adults: The members in the age should be educated, provided enough information on smoking disorders and make them quit smoking. Information should be updated within the span of 1 year from the day of first visit.

Coordination between Medical and Behavioural Health condition: If the member is approaching a Psychological health consultant there has to be a proper record coordinating between them and primary care physician. It should have full information on any existing mental disorders. Even refusal by member should also be reported in the card.

Immunization record: If Immunization has been provided, full record of the vaccines dosed with full particulars so as to date of immunization, manufacturer details, batch numbers and lot numbers. The name particulars and designation of medical attended should be provided. 11) Important health issues: Analytical view of patient’s medical requirement with overview history of health issue, symptoms, medication particulars and any other vital information must be well disclosed in the record.

Physical examination synopsis: A physical examination also known as medical examination or clinical examination is the process of check up medically or physically, whether any symptoms or signs of disease prevail. Full details should be furnished in the report.

Vital and Confidential information: Various details that are vital and key information regarding patients health such as actual health condition, diagnosis and medicines prescribed for the issue has to be described in the report.

Treatment and Recommendation: In case of a proven disease at an earlier point of time, all details of medical treatments, pathology test analysis, x-rays, total body analysis along with medication dose, frequency of illness and period of disease should be reported in the medical case record.

Unresolved medical history: Any incidents of medical issues which have not been treated properly in the past or treatment discontinued in this matter should be on record. Similarly in case of long term illness also be on record.

Follow up care: All data related to patients visit to clinic, continuation of treatment, follow up diagnosis, consultation reports and feedback from medical consultant should be available in the medical document.

Medication List: The medication list must be inclusive of all medications, whether a separate list or within each PCP progress note.

Lab/X-Ray/Diagnostic Results: The results of all labs, x-rays and diagnostic testing, should be posted in the chart. The reports should be signed or initiated by the practitioner and/or there should be a notation in the progress notes indicating that they have been reviewed.

Referral Documentation: If there is documentation of a PCP referral to another practitioner, the written referral order should be documented in the progress of the patient’s medical record.

Medical History

Teaching Aid